- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.37 / $727.37 / $909.21
| Facility | | $727.37 | $727.37 | $909.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,492.05 / $1,492.05 / $1,641.26
| Facility | | $1,492.05 | $1,492.05 | $1,641.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.05 / $1,492.05 / $1,492.05
| Professional | | $1,492.05 | $1,492.05 | $1,492.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.22 / $909.22 / $956.00
| Professional | | $909.22 | $909.22 | $956.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $395.67 / $395.67 / $395.67
| Facility | | $395.67 | $395.67 | $395.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.67 / $395.67 / $485.44
| Professional | | $395.67 | $395.67 | $485.44 |